Clomipramine

Legal status and availability in the UK

Clomipramine is a prescription-only medicine (POM) in the UK.

In our online pharmacy, clomipramine is available without a prescription, with discreet delivery to the United Kingdom in 9–21 days.

Basic clomipramine information

• INN (international nonproprietary name): Clomipramine
• Brand names available in the United Kingdom: Anafranil.
• ATC code: N06AA04 (tricyclic antidepressant, non-selective monoamine reuptake inhibitor; primarily for depression and obsessive-compulsive disorder).
• Forms and dosages: Capsules 10 mg, 25 mg and 50 mg; prolonged-release tablets 75 mg.
• Registration status in the United Kingdom: Clomipramine is licensed in the UK for obsessive-compulsive disorder and depression.
• OTC / Rx classification: Prescription-only medicine (POM)

How clomipramine is supplied

Clomipramine is a prescription-only medicine, dispensed against NHS prescriptions, private prescriptions and hospital prescriptions.

In the UK it is supplied as capsules (10 mg, 25 mg and 50 mg) and as a 75 mg prolonged-release tablet, including under the brand name Anafranil.

Indications and who benefits

Indications and realistic expectations for outcomes

Who is clomipramine for, and what should patients expect?

Clomipramine is licensed in the UK for obsessive-compulsive disorder (OCD) and depression, and is also used for some chronic pain uses.

Clinicians often reserve clomipramine for severe or treatment‑resistant OCD or depression, particularly when selective serotonin reuptake inhibitors have failed or when a tricyclic pharmacology is preferred.

Patients with comorbid chronic pain may gain secondary benefit from clomipramine’s analgesic properties in some cases.

Expect symptomatic improvement to take 4–12 weeks, with maintenance treatment often required for months to years.

Stopping treatment is best done slowly to avoid withdrawal and potential relapse.

• Licensed: use described in the official product licence for named indications such as OCD and depression.
• Off-label: prescriber may use clomipramine for unlicensed indications based on clinical judgement, for example certain chronic pain syndromes.
• Titration: the gradual increase of dose to reach an effective and tolerable maintenance level.
• Maintenance: continued treatment to prevent relapse after an initial clinical response.

Forms and strengths

Available forms

In the UK, clomipramine is available as 10 mg, 25 mg and 50 mg capsules and as a 75 mg prolonged-release tablet.

Capsules of 10 mg and 25 mg allow gentle titration, which is useful for older people and for those who are sensitive to side effects.

Check the batch number, expiry date and sealed blister packs for product integrity.

Dosing guidance and titration schedules

Practical stepwise titration and examples

How do prescribers typically start and increase clomipramine?

For adult OCD a common starter dose is 25 mg per day, increased gradually to a maintenance range often between 100–150 mg per day in divided doses.

For major depression starting at 25 mg per day with a typical maintenance range of 75–150 mg per day is common practice.

The absolute maximum daily dose is 250 mg per day according to product information.

Paediatric regimens start at around 25 mg under specialist supervision with adolescent maxima lower than adult limits in younger children.

Elderly patients should start at 10–25 mg and increase cautiously due to anticholinergic and sedative effects.

Increments of 10–25 mg every 3–7 days are typical depending on tolerability, and evening dosing initially helps reduce daytime drowsiness.

When discontinuing, slow tapering over weeks is advised to reduce the risk of withdrawal symptoms.

1. Example titration for adult OCD: Start 25 mg nightly for 3–7 days.
2. Increase to 25 mg twice daily (total 50 mg) for 1 week if tolerated.
3. Increase by 25–50 mg every 3–7 days as needed to effect until maintenance of 100–150 mg/day.
4. Do not exceed 250 mg/day without specialist review.

Contraindications and high-risk situations

Absolute and relative contraindications in practice

Which patients should not receive clomipramine or need extra caution?

Absolute contraindications include known hypersensitivity to clomipramine or other tricyclic antidepressants, recent myocardial infarction and severe cardiac arrhythmias.

Concurrent use with monoamine oxidase inhibitors is contraindicated; allow a minimum 14‑day washout after MAOI discontinuation before starting clomipramine.

Relative contraindications requiring careful monitoring include cardiovascular disease, epilepsy or a lowered seizure threshold, urinary retention or glaucoma, hyperthyroidism and significant hepatic or renal impairment.

A history of mania or hypomania is a relative contraindication and requires psychiatric review before use.

Elderly people are at increased risk of anticholinergic effects, orthostatic hypotension and falls and should have lower starting doses and close review.

• Before starting: allergy to tricyclics, recent MI, arrhythmia, current MAOI, pregnancy/breastfeeding — consult prescriber.
• If high cardiac risk: an ECG before or during initiation may be advised by the prescriber.
• Polypharmacy: the dose may need review if multiple CNS depressants or QT-prolonging drugs are present.

Side effects — counselling, prevention and management

Common, moderate and severe effects

What side effects should patients expect?

Common side effects include sedation, dry mouth, constipation, blurred vision, weight gain and sexual dysfunction.

Orthostatic hypotension and dizziness are also common and can increase fall risk, particularly in older people.

Severe effects such as cardiac arrhythmias, seizures, severe hypotension or marked mood change require urgent medical assessment.

Simple measures can reduce side effects; see the table below and seek help when needed.

• When to seek help: Palpitations, fainting, seizures, severe shortness of breath or any marked change in mood or suicidal thoughts — go to A&E or call 999.

Drug interactions and CYP metabolism

Clinically important interactions

Which medicines increase the risk of harm when combined with clomipramine?

Clomipramine is metabolised by CYP1A2, CYP2C19, CYP2D6 and CYP3A4 and is therefore vulnerable to interaction with inhibitors or inducers of these enzymes.

Strong CYP2D6 inhibitors and potent CYP1A2 or CYP3A4 inhibitors can raise clomipramine plasma levels and increase toxicity risk.

Combining clomipramine with other serotonergic drugs, particularly SSRIs, can increase the risk of serotonin syndrome, so switching or combining requires careful planning and monitoring.

Concurrent use with MAOIs is contraindicated because of severe interactions; observe a 14‑day washout when switching between MAOIs and clomipramine.

QT‑prolonging drugs, anticholinergics and agents that lower seizure threshold should be used with caution or avoided.

• Do not combine: MAOIs and clomipramine; potent CYP inhibitors without dose review.
• Use with caution: SSRIs (risk of serotonin syndrome), QT‑prolonging agents and drugs that lower seizure threshold.
• Action: an ECG may be requested if there is a QT risk, and the prescriber may adjust the dose or choose an alternative.

Monitoring, investigations and safety checks for ongoing use

Baseline and periodic checks

What baseline tests and ongoing monitoring are advised?

Baseline checks include ECG for patients with cardiac risk or elderly patients, liver and renal function where impairment is suspected and a medication review for interactions.

Measure baseline blood pressure, including orthostatic readings, and document weight and bowel habit history.

Ongoing monitoring should include repeat ECG for dose increases or when adding QT‑prolonging drugs, weight checks and assessment of metabolic effects where relevant.

Monitor bowel function, sexual side effects and mood including suicidality, particularly in the early weeks after initiation or dose changes.

Consider serum level monitoring in complex polypharmacy or significant hepatic impairment where clearance is reduced.

Suspected side effects can be reported to the MHRA Yellow Card scheme.

• Baseline: ECG if cardiac risk, BP and orthostatic vitals, LFTs/renal function if suspected impairment.
• Ongoing: ECG after dose increase, weight, bowel habits, mood checks at 2, 6 and 12 weeks.
• Reporting: serious side effects can be reported to the MHRA Yellow Card scheme.

Special populations — children, elderly, pregnancy and hepatic impairment

Tailored advice and dose adjustments

How should clomipramine be used in groups needing special care?

Children and adolescents should only be treated under specialist supervision, starting on low doses such as 25 mg.

Monitor growth, behaviour, suicidality and consider ECG where indicated in paediatric patients.

Elderly patients should start at 10–25 mg with very slow titration and frequent review because of anticholinergic effects, orthostatic hypotension and falls risk.

Pregnancy and breastfeeding require individual risk‑benefit discussion with the obstetric or psychiatric team and specialist input where necessary.

In hepatic or renal impairment start lower and titrate carefully because reduced clearance increases toxicity risk; consider serum monitoring in significant dysfunction.

Overdose management and emergency advice

Recognising overdose and immediate actions

What should be done if overdose is suspected?

Symptoms of clomipramine overdose include confusion, seizures, cardiac arrhythmias, severe hypotension and respiratory depression and can be life‑threatening.

Immediate medical assessment is required and patients or carers should be advised to call 999 or go to the nearest A&E if overdose is suspected.

Store the medicine safely to prevent accidental ingestion, especially by children.

In hospital, activated charcoal may be considered if the patient presents early, and ECG monitoring with cardiac support are mainstays of management.

Return leftover medicines to a pharmacy to reduce the risk of accidental or intentional overdose.

• Emergency steps: Recognise severe symptoms, call 999, bring medication packaging to A&E, do not induce vomiting at home unless instructed.
• Prevention: Store medicines in original packaging out of sight and reach of children and return unused supplies to the pharmacy.

Switching, stopping and avoiding discontinuation syndrome

Tapering and switching antidepressants

How should clomipramine be stopped or switched to another antidepressant?

Taper gradually over weeks to months depending on dose and duration to avoid discontinuation symptoms such as nausea, headache, irritability and sleep disturbance.

When switching to or from an MAOI observe a 14‑day washout period to avoid serious interactions.

Cross‑tapering with SSRIs or other TCAs is usually planned by the prescriber and monitored closely for serotonin syndrome if serotonergic agents overlap.

A pharmacist can advise on gradual reduction and on telling withdrawal apart from relapse.

1. Example taper: Reduce dose by 10–25 mg every 1–2 weeks depending on baseline dose and tolerability.
2. Switching to an SSRI: Consider gradual reduction of clomipramine with delayed initiation of the new agent as per specialist guidance to avoid overlap.
3. When in doubt: Liaise with prescriber for cross‑taper instructions and safety monitoring.

Comparing clomipramine with alternatives

When clomipramine is preferred

When might a clinician choose clomipramine over other options?

Clomipramine is often more effective for obsessive‑compulsive disorder than many SSRIs but carries a higher burden of anticholinergic effects, cardiac risk and sedation.

SSRIs such as fluoxetine and sertraline are generally preferred first‑line for tolerability, with clomipramine reserved for SSRI‑resistant OCD or where a tricyclic mechanism is specifically desired.

Other TCAs like imipramine, amitriptyline and nortriptyline may be considered where TCA class effects are needed, each with different side‑effect and dosing profiles.

Choice between clomipramine and alternatives is a shared decision that weighs efficacy differences, tolerability and monitoring needs.

Delivery across the United Kingdom